QUT NSB335 Case Study: Managing Ethel Simpson's Post-Op Recovery

This case study analyzes the nursing priorities in the care of Ethel Simpson, a 64-year-old patient undergoing left knee arthroplasty with pre-existing conditions of dementia, arthritis, hypertension, diabetes and mild renal failure. The analysis covers pre-admission assessment, risk factors for injury, medication considerations (Aricept), mental status examination tools (MMSE), and post-operative management. Key aspects include pain assessment (Abbey Pain Scale), nutritional needs, and interprofessional referrals (nutritionist) to address her poor appetite and weight loss. The study also addresses common myths about dementia and aging, emphasizing the importance of individualized care and understanding the complex interplay between musculoskeletal problems, dementia, and injury prevention. This document is available on Desklib, offering a valuable resource for students seeking solved assignments and past papers.

URN: QUT174801 | PATIENT: SIMPSON,
Ethel Merle
This case study is based on Mrs. Ethel Simpson who is 64 years old. She attends
the pre-admission clinic with her grand-daughter to discuss her up-coming left
knee arthroplasty. Later, she undergoes the surgery and is then three days post-
operative, in the orthopaedic ward.
You will need to access the Mrs Simpson Simulation Case Study resource in your
Blackboard site to view medical documents and the three videos that tell the story
of Mrs Simpson.

Caring for a patient with dementia and arthritis who is at risk of injury
Setting the scene
Social:
Ethel is 64 years old and lives in a Granny flat attached to her daughter’s
home. She has good support from this daughter and grand-daughter, and
her other two children who visit at least weekly. She was previously a
registered nurse. She has six steps in her house that she needs to
negotiate. Her worsening arthritis, particularly the arthritis in her left knee has
made it extremely difficult for her to leave the house in the last two months.
Ethel complains of poor appetite, difficulty sleeping and not wanting to leave the
house.
Ethel was diagnosed with Alzheimer’s dementia a year ago and has been partially independent in all
her basic activities of daily living. She is continent but needs assistance with bathing and household
activities such as cleaning. She can cook basic meals and feed herself. Cognitively she is oriented to
person, place and year. She can recall 3 out of 3 words immediately, but 0 out of 3 words at 5 minutes.
Her attention is intact.
Mrs Simpson and her family sought advice from her GP because of the worsening pain of her arthritis,
particularly in her knee and the impact this was having on her mobility. After being referred to an
orthopaedic surgeon for review, the decision was made for a knee arthroplasty to be done.
Epidemiology / pathophysiology of disease processes
The National Health Priority Areas of Arthritis and Musculoskeletal conditions, Dementia and Injury
Prevention and Control were established with the aim of improving health outcomes in these areas.
Musculoskeletal conditions are conditions of the bones, muscles and their attachments (e.g. joints and
ligaments). Osteoarthritis, rheumatoid arthritis and osteoporosis are the most commonly occurring
musculoskeletal conditions. They have substantial influence on the quality of life and impose a heavy
economic burden on the community.
Injuries are adverse effects on the human body. They are a significant source of preventable illness,
disability and premature death in Australia.
Dementia is defined as the loss of mental processing ability, including communication, abstract
thinking, judgment and physical abilities, such that it interferes with daily living. Conditions
associated with dementia are typically progressive, degenerative and irreversible, for which there is
currently no cure.
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Your Task:
Use the Clinical Reasoning Cycle on the following pages to review the nursing priorities in relation to
the care of Ethel.
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Watch the two videos – Pre-admission Clinic and At home
Gain an initial impression of
your patient
Question 1:
Review the anatomy and physiology of the three
musculoskeletal conditions listed above (osteoarthritis,
rheumatoid arthritis and osteoporosis).
What type of arthritis do you think that Ethel has?
Explain the rationale for your answer.
Your Answer:
Osteoarthritis is a common arthritis that targets the elderly patient population, The
anatomical and patho-physiological features include break\down and
eventual loss of cartilage or more joints (Hochberg et al., 2012, pp. 465-474).
Rheumatoid arthritis is a autoimmune disorder where the immune system of the
patient facilitates the targeting of the lining of the joints giving rise to
inflammation.
Osteoporosis is a condition of the fragile bones with increased susceptibility to
fracture.
The patient in this case is suffering from Osteoarthritis.
As the patient is 64 years old and is going to be undergoing arthoplasty which is a
common surgical intervention for osteoarthritis, she is suffering from osteoarthritis
(Hochberg et al., 2012, pp. 465-474). Apart from old age, obesity, women gender,
knee injury and muscle weakness also increases the risk of osteoarthritis. As Ethel
belongs to the female sex and females have high density of adipose derive leptin
concentration, she is regarded to be suffering from osteoarthritis (Heidari, 2015, pp.
205–212).
Question 2:
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Gain an initial
impression of your
patient.
List three variables that put Ethel at risk of injury. Justify your
answer.
Your Answer:
The patient is case study, Ethel, has been suffering from dementia and
osteoarthritis. The three variables that put Ethel at risk of injury includes the
following:
 The first factor is her age as she is 64 years old. Ageing increases chance of
injury and risk of fall because of risk of balance impairment and reduced limb
strength due t the natural aging process (Bird et al., 2013, 5989–5997).
 The second factor is her mobility restriction due to pain in the left knees. Her
house has six steps that she needs to negotiate and pain in the knees can
lead to injury while using the stairs.
 The third variable that increases risk of injury is her dementia. Patients with
dementia are twice likely to fall than elderly people because of neuro-
cognitive disability (Aizen, 2015, pp. 323-326).
Question 3:
Review and recall knowledge from NSB132 on dementia as it is
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Gain an initial
impression of your
patient.
important to understand the type of dementia that Ethel has.
What statement best describes Alzheimer’s dementia?
a) Occurs through a reduced blood supply to the brain and
accounts for around 20% of dementia cases.
b) Is associated with Lewy bodies and accounts for around
15% of dementia cases.
c) Is associated with shrinkage/atrophy of the brain and
accounts for around 50% of dementia cases.
d) Is associated with tangled bundles of proteins in brain nerve
cells with an earlier age of onset and accounts for around
5% of dementia cases.
Your Answer:
c.) Is associated with shrinkage/atrophy of the brain and accounts for around 50%
of dementia cases (Johnson et al., 2012, pp. p. a006213)
Gain an initial
impression of your
patient.
Question 4:
Aricept is a commonly used medication to treat mild to moderate
dementia caused by Alzheimer’s disease.
a) Briefly describe the mode of action of this medication for
Ethel (1 mark)
b) How should the medication be taken?
c) List two side effects of the medication
Your Answer:
Aricept or donepezil is a medication given to dementia patient to treat confusion. It
is an enzyme blocker that works to improve memory by restoring the balance of
neurotransmitters in the brain (drugbank.ca, 2018).
Ethel will need to take the medication orally with or without food depending
on the instruction of the medical practitioner caring for the patient. According to
the general administration guidelines for Aricept, Ethel will need to take the
medication once daily before bedtime (Cummings et al., 2016, . . pp. 159-166).
Two side effects that Ethel may experience due to taking Aricept for her
dementia includes: nausea and diarrhea.
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Gain an initial
impression of your
patient.
Question 5:
When the family first became concerned about Mrs Simpson’s
cognitive status, they visited the GP. She referred Ethel to you as a
practice nurse for a further examination of mental status. There are
many cognitive tools available that you might use.
a) Name one that would be applicable to use
b) Justify your use of this tool for Ethel.
Your Answer:
Mini mental state examination can be used as a mental health assessment tool for
Ethel to assess her mental health status.
MMSE or the mini mental state examination is a very common tool to be
utilized for dementia as it is a simple and time saving questionnaire based
tool that helps in assessing the cognitive status and be able to correctly
diagnose dementia within 10 minutes (Travis, Kao & Acton, 2016, pp. 13-15).
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Now watch the video Mrs. Simpson – In the Ward
Further background information
Past medical history
 DMII (diagnosed 10 years ago)
 Mild renal failure (diagnosed 2 years ago)
 Hypertension (diagnosed 15 years ago)
 Dementia (diagnosed 1 year ago)
 Arthritis (diagnosed 6 years ago)
Surgical history:
 Hysterectomy
 cholecystectomy.
Medications:
Ibuprofen, Aricept (donepezil), Micardis (telmisartan), temazepam, metformin
Ethel is day 3 post-operative left total knee arthroplasty. She has an IV cannula still in place.
Her neurovascular obs are fine. The toes of that left leg have been pink and warm with full movement
and sensation, pulses normal.
Her left knee had a waterproof dressing in place however there was visible purulent ooze overnight and
the dressing was removed this morning in the shower and the surrounding skin was inflamed. A wound
swab was taken yesterday evening and sent for culture.
She has been doing deep breathing and leg exercises. She has been resting quietly and has been
pleasant and cooperative with staff this morning.
0500 vital signs: BP 174/80 mmHg; HR 88 BPM; RR 18 BPM; O2 sats 98%; Temperature 37.7
degrees.
Weight: 68kg (down from 71kg one month ago)
(a)Review current
information
(b)Gather new information
(c)Recall knowledge (A&P,
ethics, law, cultural
safety)
Question 6:
Fall related hospitalisation is particularly common among older
people. Of these more were males than females. True or False?
Your Answer:
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False (Aihw.gov.au, 2018).
(a)Review current
information
(b)Gather new information
(c)Recall knowledge (A&P,
ethics, law, cultural
safety)
Question 7:
In the video Ethel is cooperative and forgetful.
a) Name a suitable pain assessment tool you could use to
assess her pain.
b) Justify your choice of this tool, taking into account Ethel’s
responses to the questions in the video.
Your Answer:
The pain assessment tool that can be used in the patient includes the Abbey
pain scale. It is validated tool to assess pain in patients with late dementia
It has to be mentioned that when asked to describe the pain she had been
feeling and score it in a scale of 0 to 10, she could not score her pain and only
stated it is very bad. Hence, use of Abbey pain scale may help to assess pain in
patients who cannot articulate their needs. Pain is scored on the scale of no pain,
mild, moderate and severe pain (Brown, 2011, pp. 18-22).
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Interpret data – what does
it all mean?
It is important to consider
the potential inter-
relationships between
dementia,
musculoskeletal problems
and injury prevention.
Question 8:
Ethel has indicated that she currently has a poor appetite and
has lost 3kgs in the last month.
a) What allied health professional would you consider referring
Ethel to?
b) Give a rationale for your answer
Your Answer:
I will refer her to a nutritionist so that her particular nutritional needs can be
identified and accordingly a specialized diet plan can be made for her. This is also
important so that she does not suffers from ill-health because of poor appetite. The
nutritionist can determine self-feedining abilities degree of diet tolerance and ideal
food for Ethel (Nelson et al., 2014, pp. 701-712).
Interpret data – what does
it all mean?
Question 9:
There are many myths about older people and dementia. Which of
the following statements is true?
a. All older people will develop dementia
b. Some level of confusion is experienced by most older
people
c. Dementia is not a natural part of ageing
d. All older people will lose their short-term memory
Your Answer:
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c.
Old age is associated with a few health restrictions and the reduction in the
cognitive functioning is one of the most abundant changes that are brought
forward due to aging. According to the recent report, the incident rates of 3Ds
(Delirium, Depression and Dementia), is also alarmingly high in the elderly
populations, among which delirium is most common. It has to be mentioned that
with aging, a small percentage of baseline cognitive functioning decreases paving
way for delirium. Hence, small level of confusion is experienced by most of the
older people however the probability of developing delirium or related mental
disorders is dependent on the age, genetic predisposition and severity of the
cognitive impairment (Thomas et al., 2012, 1471-1477).
………………………………………………………………………………………………………………………
…………………………………………
Synthesise all information
that has been collected
and processed.
Question 10:
Select from the list below the three highest priority relevant
nursing diagnoses for Ethel. Justify your answer.
a) Impaired balance
b) Acute confusional state
c) Cognitive impairment
d) Insomnia
e) Pain
f) Signs of infection in left knee
g) Altered nutrition/hydration
h) Antisocial personality disorder
Your Answer:
The first nursing priority nursing diagnosis for Ethel will be the Pain, as the
patient had been suffering from osteoarthritis. In the initial patient assessment
interview, Ethel had stated the fact that Ethel had been suffering from due to which
she had to undergo a knee replacement surgery. In the postoperative period, as
well as soon as her pain relief medication wore off, she began to feel an
excruciating pain, which is very commonly observed in case of knee replacement
surgery. Hence, the pain management is the first nursing priority (Lockwood, Kable,
& Hunter, 2018, pp. e1048-e1060.).
The second nursing diagnosis is the nutritional impairment. In justification, it
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can be mentioned that the patient had been reported to be experiencing loss which
led to her losing 3 kg in the past month. In the post operative state, as she had
high blood sugar as well, the lack of proper nutrition can slow down her recovery
progress and can even cause hyperglycemic attack.
The third nursing priority for the patient will be the risk of falling which can
lead to injuries. Ethel had been suffering from osteoarthritis for which she had to
undergo a knee replacement surgery. Hence, the patient had been extremely
mobility restricted and as there had not been any bed rails in the cabin she was
staying in, the risk of fall was very high (Lockwood, Kable, & Hunter, 2018, pp.
e1048-e1060).
As a nurse, what are your
desired outcomes for
Ethel?
Question 11:
From the list below choose the three most important short-
term goals for Ethel’s management at this time: Justify your
answer.
a) For Ethel’s weight to stabilise
b) For Ethel to sleep for eight hours/night
c) For Ethel’s pain to be managed
d) For Ethel to be more social
e) To ensure the prevention of injury for Ethel
f) For Ethel to be placed in a residential aged care facility
g) For Ethel’s wound infection to be treated.
Your Answer:
The three short term goals for Ethel are:
 For Ethel’s pain to be managed: as mentioned above the patient had been in
excruciating pain post her surgery and Ethel had been increasingly getting restless
due to the pain that she had been feeling and hence the first short term goal for her
will be pain management
 For Ethel’s wound infection to be treated: in the post operative scenario for Ethel, it
has been discovered that her excruciating pain had been due to the hospital
acquired infection in the surgical wound after her surgery. According to Lockwood,
Kable, and Hunter (2018, e1048-e1060), Hospital acquired infections are the
primary factors contributing to many complications for the patient other than the
pain and can lead to fatal consequences like sepsis if not treated immediately.
 To ensure the prevention of injury for Ethel: As she had been an elderly patient with
mobility restrictions due to her arthritis and the surgery, she is at increased risk of
fall injuries. Her confused mental state and restlessness due to the increasing pain
further enhances the risk, hence, prevention of injury is very important for Ethel’s
safety.
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